Acute Situations: Trauma in Surgical Specialties

  • Sandra Giannone
  • Daniela Ghisi
  • Andrea Fanelli
  • Carl C. Rest


Pain is the most common symptom reported by trauma patients entering the Emergency Department. Treatment has a crucial role in trauma, since adequate pain management leads not only to increased patient comfort and satisfaction, but also to reduced morbidity (such as pulmonary complications or thromboembolic events), shorter length of stay, and improved long-term outcomes. Unfortunately, multiple studies have reported that trauma-related pain is still inadequately controlled. Loco-regional anesthesia, e.g., peripheral nerve blocks, is emerging as an important technique that can be applied at the patient admission to the Emergency Department, and maintained through the perioperative setting. Regional anesthesia can become the first choice of analgesia in patients with isolated orthopedic injuries and burning injuries because this technique is devoid of many adverse effects associated with systemic opioids. Brachial plexus blocks can provide excellent analgesia for upper extremity trauma; lumbar plexus block and sciatic nerve block, both performed at different sites, can be used for lower extremity fractures, while epidural, paravertebral, intercostal, and interpleural block can provide analgesia for thoracic trauma. Some peculiar features of the trauma patients, such as acute blood loss, trauma associated coagulopathy, and the threat of compartment syndrome, must be kept in mind and pose an extra challenge to the choice of the optimal pain management technique.


Trauma Pain management Nerve block Humeral fractures Shoulder fractures Hip fractures Femoral fractures Compartment syndromes Brachial plexus block Lumbosacral plexus Rib fractures Analgesia Epidural Paravertebral block Intercostal nerve block Interpleural analgesia 


  1. 1.
    Cordell WH, Keene KK, Giles BK, et al. The high prevalence of pain in emergency medical care. Am J Emerg Med. 2002;20(3):165–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Rosenberg A, Grande C, Bernstein R. Pain management and regional anesthesia in trauma. Philadelphia, PA: WB Saunders; 2000.Google Scholar
  3. 3.
    Clark L, Varbanova M. Regional anesthesia in trauma. Adv Anesth. 2009;27:191–222.CrossRefGoogle Scholar
  4. 4.
    Davidson EM, Ginosar Y, Avidan A. Pain management and regional anaesthesia in the trauma patient. Curr Opin Anaesthesiol. 2005;18:169–74.CrossRefPubMedGoogle Scholar
  5. 5.
    Cohen SP, Christo PJ, Moroz L. Pain management in trauma patients. Am J Phys Med Rehabil. 2004;83:142–61.CrossRefPubMedGoogle Scholar
  6. 6.
    Tuman KJ, McCarthy RJ, March RJ, et al. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg. 1991;73:696–704.CrossRefPubMedGoogle Scholar
  7. 7.
    Sorenson RM, Pace NL. Anesthetic techniques during surgical repair of femoral neck fractures: a meta-analysis. Anesthesiology. 1992;77:1095–104.CrossRefPubMedGoogle Scholar
  8. 8.
    Liu SS, Carpenter RL, Macket DC, et al. Effects of perioperaitve analgesic technique on rate of recovery after colon surgery. Anesthesiology. 1995;83:757–65.CrossRefPubMedGoogle Scholar
  9. 9.
    Yeager MP, Glass DD, Neff RK, et al. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology. 1987;66:729–36.CrossRefPubMedGoogle Scholar
  10. 10.
    Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science. 2000;288:1765–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Turner JA, Cardenas DD, Warms CA, et al. Chronic pain associated with spinal cord injuries: a community survey. Arch Phys Med Rehabil. 2001;82(4):501–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Rotondi AJ, Chelluri L, SIrio C, et al. Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med. 2002;30:746–52.CrossRefPubMedGoogle Scholar
  13. 13.
    Whipple JK, Lewis KS, Quebbeman EJ, et al. Analysis of pain management in critically ill patients. Pharmacotherapy. 1995;15:592–9.CrossRefPubMedGoogle Scholar
  14. 14.
    American College of Surgeons (ACS) Committee on Trauma. Advanced trauma life support for doctors: ATLS student course manual. Chicago: ACS; 2008.Google Scholar
  15. 15.
    Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Malchow RJ, Black IH. The evolution of pain management in the critically ill trauma patient: emerging concepts from the global war on terrorism. Crit Care Med. 2008;36(7 suppl):S346–57.CrossRefPubMedGoogle Scholar
  17. 17.
    Gregoretti C, Decaroli D, Miletto A, Mistretta A, et al. Regional anesthesia in trauma patients. Anesthesiol Clin. 2007;25:99–116.CrossRefPubMedGoogle Scholar
  18. 18.
    Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve blocks provide superior pain control to opioids? A meta-analysis. Anesth Analg. 2006;102:248–57.CrossRefPubMedGoogle Scholar
  19. 19.
    Le-Wendling L, Enneking FK. Continuous peripheral nerve blocks for postoperative analgesia. Curr Opin Anaesthesiol. 2008;21:602–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Plunkett AR, Buckenmaier CC. Safety of multiple, simultaneous continuous peripheral nerve block catheters in patients receiving therapeutic low-molecular weight heparin. Pain Med. 2008;9:624–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Pogatzki-Zahn EM, Zahn PK. From preemptive to preventive analgesia. Curr Opin Anaesthesiol. 2006;19(5):551.CrossRefPubMedGoogle Scholar
  22. 22.
    Moiniche S, Kehlet H, Dahl JB. A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief: the role of timing of analgesia. Anesthesiology. 2002;96:725–41.CrossRefPubMedGoogle Scholar
  23. 23.
    de Tran QH, Munoz L, Russo G, et al. Ultrasonography and stimulating perineural catheters for nerve blockade: a review of evidence. Can J Anaesth. 2008;55:447–57.CrossRefPubMedGoogle Scholar
  24. 24.
    Plunkett AR, Brown DS, Rogers JM, et al. Supraclavicular continuous peripheral nerve block in a wounded soldier: when ultrasound is the only option. Br J Anaesth. 2006;97:715–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Delaunay L, Chelly JE. Indications for upper extremity blocks. In: Chelly JE, editor. Peripheral nerve blocks: a color atlas. Philadelphia, PA: Lippincott Williams and Wilkins; 1999. p. 17–27.Google Scholar
  26. 26.
    Sala-Blanch X, Lazaro JR, Correa J, et al. Phrenic nerve block caused by interscalene brachial plexus block: effects of digital pressure and a low volume of local anesthetic. Reg Anesth Pain Med. 1999;24:231–5.CrossRefPubMedGoogle Scholar
  27. 27.
    Jandard C, Gentili ME, Girar DF, et al. Infraclavicular block with lateral approach and nerve stimulation: extent of anesthesia and adverse effects. Reg Anesth Pain Med. 2002;27:37–42.PubMedGoogle Scholar
  28. 28.
    Taras JS, Behrman MJ. Continuous peripheral nerve block in reimplantation and revascularization. J Reconstr Microsurg. 1998;14:17–21.CrossRefPubMedGoogle Scholar
  29. 29.
    Fletcher AK, Rigby AS, Boughrouph J, et al. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2003;41:227–33.CrossRefPubMedGoogle Scholar
  30. 30.
    Sia S, Pelusio F, Marbagli R, et al. Analgesia before performing a spinal block in the sitting position in patients with femoral shaft fracture: a comparison between femoral nerve block and intravenous fentanyl. Anesth Analg. 2004;98:1785–8.Google Scholar
  31. 31.
    Chesters A, Atkinson P. Fascia iliaca block for pain relief from proximal femoral fracture in the emergency department: a review of the literature. Emerg Med J. 2014;31:84–7.CrossRefGoogle Scholar
  32. 32.
    Wathen JE, Gao D, Merritt G, Georgopoulos G, Battan FK. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med. 2007;50(2):162–71.CrossRefPubMedGoogle Scholar
  33. 33.
    Capdevila X, Biboulet P, Bouregba M, et al. Comparison of the three-in-one and fascia iliaca compartment blocks in adult: clinical and radiographic analysis. Anesth Analg. 1998;86:1039–44.CrossRefPubMedGoogle Scholar
  34. 34.
    Chelly JE, Casati A, Al-Samsam T, et al. Continuous lumbar plexus block for acute postoperative pain management after open reduction internal fixation of acetabular fractures. J Orthop Trauma. 2003;17(5):362–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Neuburger M, Buttner J, Blumenthal S, et al. Inflammation and infectious complications of 2295 perineural catheters: a prospective study. Acta Anaesthesiol Scand. 2007;51:108–14.CrossRefPubMedGoogle Scholar
  36. 36.
    McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome: who is at risk? J Bone Joint Surg Br. 2000;82:200–3.CrossRefPubMedGoogle Scholar
  37. 37.
    Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg. 2005;13:436–44.CrossRefPubMedGoogle Scholar
  38. 38.
    McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br. 1996;78:95–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Hyder N, Kessler S, Jennings AG, et al. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg Br. 1996;78:449–500.Google Scholar
  40. 40.
    Strecker WB, Wood MB, Bieber EJ. Compartment syndrome masked by epidural anesthesia for postoperative pain. J Bone Joint Surg Am. 1986;68:1447–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Moed BR, Thorderson PK. Measurement of intracompartmental pressure: a comparison of the slit catheter, side-ported needle and simple needle. J Bone Joint Surg Am. 1993;75:231–5.CrossRefPubMedGoogle Scholar
  42. 42.
    Mowbray A, Wong KK, Murray JM. Intercostal catheterisation. An alternative approach to the paravertebral space. Anaesthesia. 1987;42(9):958–61.CrossRefPubMedGoogle Scholar
  43. 43.
    Carrier FM, Turgeon AF, Nicole PC, Trépanier CA, Fergusson DA, Thauvette D, Lessard MR. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. 2009;56(3):230–42.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Sandra Giannone
    • 1
  • Daniela Ghisi
    • 1
  • Andrea Fanelli
    • 2
  • Carl C. Rest
    • 3
  1. 1.Department of Anesthesia, Intensive Care and Pain ManagementRizzoli Orthopedic InstituteBolognaItaly
  2. 2.Department of Anesthesiology and Pain ManagementPoliclinico Sant’Orsola-MalpighiBolognaItaly
  3. 3.Department of Anesthesia and AIPPSUniversity of Pittsburgh Medical CenterPittsburghUSA

Personalised recommendations